Learning from the End of the Public-Private Partnership for Lesotho’s National Referral Hospital Network

Background: Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho’s Queen ‘Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa’s first and largest integrated healthcare PPP. Objective: We assessed successes and challenges to performance of the QMMH-IN PPP. Methods: We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis. Findings: Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN’s role as a training facility. Conclusions: The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.


INTRODUCTION
Ensuring access to high quality healthcare for people of all ages, in the setting of rising medical costs, is a complex challenge globally.Since the 1990s, governments in high-and, more recently, lower-resource settings have looked to healthcare public-private partnerships (PPPs) as a way to respond to this challenge [1,2].PPPs are long-term, formalized contracts between the public and private sectors to provide services in a way that leverages the different strengths of each partner.Financial and operational risk is transferred to the private partner, who is accountable for defined outcomes such as quality metrics.The public partner retains ownership of the facility and equipment at the end of the contract [3].Integrated PPPs add the delivery of clinical services within the private partner's scope and are designed to create long-lasting improvements to the health sector via the combined investment in health capital and service provision [1].A recently published review of hospital PPPs globally, however, suggests mixed results on hospital performance indicators and highlights important challenges to implementation including resources, trust and communication, and the policy context [4].
Sub-Saharan Africa's first and largest integrated healthcare PPP was opened in 2010-11 as a partnership between the Ministry of Health of Lesotho and T'sepong, a consortium of Basotho and South African companies headed by Netcare, a large private hospital network based in South Africa [5].A primary goal of this 18-year PPP agreement was to replace the 100-year-old national referral hospital, Queen Elizabeth II (QEII), through the design, construction, and operation of Queen 'Mamohato Memorial Hospital (QMMH).Under the agreement the private partner also constructed a new Gateway ambulatory clinic on the hospital campus and renovated three filter clinics which provide outpatient primary care services and inpatient deliveries in the capital city of Maseru.QMMH and its four affiliated clinics are referred to collectively as the QMMH Integrated Network (QMMH-IN).This strategy of bundling both hospital and primary health care services within an integrated PPP is often referred to as the Alzira Model, named after the first hospital system in Spain, to pioneer this PPP strategy [6,7].Details regarding the QMMH-IN PPP, its history, and prior evaluations are described elsewhere [1,5,[8][9][10].
The PPP contract stipulated specific quality standards under which the network was to operate, ranging from waste management to personnel training metrics.If any standard was not met, the government could deduct a specific percentage from the monthly payment made to T'sepong.Two structures for monitoring these standards were employed.First, the consulting firm Turner & Townsend-referred to as "the independent monitor," was engaged to monitor these standards quarterly [1].Second, QMMH leadership was required to achieve and maintain accreditation by The Council for Health Service Accreditation of Southern Africa (COHSASA), a regulatory body for health services in southern Africa, which conducts monitoring and re-accreditation processes.QMMH facilities were first accredited in 2013 and they maintained accreditation status through February 2022 [11].
An evaluation comparing QEII performance data from 2006-7 to QMMH-IN performance data from 2012 found that the network increased quality of care, delivered more services, and produced better outcomes, including reduction in overall mortality by 41% in its first year [5].Interviews conducted with the executive leadership team, department heads, and staff in 2013 ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening.Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP.Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

STUDY SETTING
The Kingdom of Lesotho is a small, mountainous, lower-middle income country surrounded by South Africa, with a population of approximately 2.1 million.HIV remains the primary cause of death, followed closely by tuberculosis, and, as of 2017, life expectancy was 59 years for females and 50 years for males [18].In 2020, an estimated 31% of the population lived under the international poverty line of $1.90 USD per day, with poverty highly concentrated in rural areas [19].Just 29% of the population lives in urban parts of the country [20].
QMMH-IN is in Lesotho's capital city of Maseru, the country's major urban center.The three filter clinics operated under the QMMH-IN are spread throughout Maseru district and opened in May 2010.The ambulatory Gateway clinic and QMMH, which included an intensive care unit (ICU) and a neonatal intensive care unit (NICU), opened on the same hospital campus in October 2011.After QMMH replaced the old QEII in 2011, there was no separate publicly funded district hospital for Maseru.QEII reopened as an outpatient-only facility in 2014.As of 2018, QMMH was the only higher-level hospital in the area.It had 434 operational beds, with the three filter clinics adding a combined 24 additional short-term obstetric beds.Across the network, a total of 582 clinicians, including 295 registered nurses and 85 physicians were employed.In 2018 QMMH saw 24,796 admissions, with an average length of stay of 6.5 days and a bed occupancy rate of 99% [10].

DATA COLLECTION
We conducted semi-structured key informant interviews with the executive team, department heads, and staff working at QMMH-IN facilities.We purposively selected respondents using a maximum variation strategy to include clinical and non-clinical roles from all levels of the organization (ranging from executive management to nursing assistants to support staff) [21].We included those who worked at the main QMMH hospital, as well as the Gateway clinic and each filter clinic.We sought to include at least one from each clinic and hospital department.The study team provided a list of positions to hospital administrators who assisted in the identification

ETHICAL ISSUES
The Ministry of Health Research and Ethics Committee in Lesotho (Protocol 230-2019) and the Boston University Medical Campus Institutional Review Board (Protocol H-39448) approved the study.The interviewers (JLK, TN) were trained in research ethics, the overarching study, and the specific interview guides.After introducing themselves, interviewers shared an information sheet with each respondent about the study and described study objectives, potential risks, benefits, and guarantees of confidentiality, addressing respondent questions and concerns.Verbal informed consent was obtained for each interview and audio recording.Respondents skipped questions they were not comfortable answering.No individual refused to participate or withdrew.Interviews were conducted in a private office, with only the interviewer and respondent present.Data are presented in aggregate form and anonymized to ensure responses remain confidential.

DEMOGRAPHIC CHARACTERISTICS
The mean age among respondents was 43.3 years (standard deviation [SD] 8.4 years) and just over half were female.Twenty-one respondents (80.8%) worked at QMMH, while five worked at the network clinics.Sixteen (62.5%) held clinical roles.Fifteen (57.7%) were in higher management positions, and respondents had been employed in the PPP for an average of 7.7 years (SD 2.5 years) (Table 1).

FACILITATORS OF QMMH-IN PERFORMANCE
Three major themes emerged as facilitators of QMMH-IN performance: (1) a commitment to quality improvement supported by protocols, monitoring, and actions; (2) high levels of accountability and discipline; and (3) well-functioning infrastructure, core systems, workflows, and internal referral network (Table 2).

Protocols, monitoring, and quality improvement
The first driver of QMMH-IN performance was a dedication to quality improvement (QI) facilitated by use of clinical protocols, internal and external monitoring, and steps taken to address quality gaps.
Clinical protocols: There was broad agreement that the availability and routine use of specific clinical care guidelines and protocols, sometimes referred to as standard operating procedures for care, were key drivers of quality clinical care.Following evidence-based practices was perceived to lead to improved patient outcomes and thus network performance (Table 2, quotes a-b).
Internal and external monitoring: Respondents emphasized that they perceived monitoring at QMMH-IN to be regular and consistent.A variety of internal monitoring structures were described as facilitating performance.For example, respondents' spoke about routine clinical audits to identify opportunities for targeted training, updates to the clinical protocols, or quality improvement projects (Table 2, quotes c-d).Monitoring also included risk assessments and ratings of departments based on the frequency of adverse events, near misses, and sentinel events (Table 2, quote d).Respondents discussed regular evaluation visits by the external Independent Monitor who assessed everything from hand-hygiene to waste management, as well as the pressure to maintain COHSASA accreditation standards (Table 2, quotes e-f).
Taking action to improve quality: Respondents reported that the gaps identified through monitoring activities resulted in actions that, in turn, improved performance.They emphasized how quality improvement and risk mitigation are taken seriously (  6. Disciplinary actions taken to help ensure quality m) "If you don't perform or you are found guilty of mismanagement of patients, steps are taken about such individuals.Some of them had to be sacked because of those reasons, and you hardly find that happening in a government setup.These things make people stand on their toes (…) I think this is [a] positive change."-QMMH higher management, clinical rolen) n) "A receipt is given to every single service that has been done.Stickers and receipts are verified.We had discrepancies where we found that the clinics, their payments were done but were not dropped in the safe.And a whole lot of employees were fired and disciplinary [meetings] were held (…) They are very particular in checking.Yes, there will be loopholes, [but] when we find them, we do something about it."-QMMH staff, non-clinical role

Accountability systems, such as biometric clocking
and employee numbers, promoted professionalism and discipline which led to increased quality o) "You account for every minute of your time.We do a biometric clocking system.Those are things that don't exist in the [public] health sector.This culture in the private sector makes a difference in terms of outputs."-QMMH higher management, non-clinical rolep) p) "The cashiers use [an] employment number which they enter in the [accounts] system.During lunch time when they are being relieved, they have to balance their money, drop it in the safe, and then go for lunch.Whoever is coming in, she also is going to use her employment number so there is not going to be any mixed ups."-QMMH higher management, non-clinical role q) "We are disciplined because of the kind of management we have.

Accountability and discipline
Respondents explained that the focus on QI at QMMH-IN translated to policies, tools, and other factors that promoted a high level of individual accountability and discipline.
Clear roles and policies: Respondents reported to have clarity regarding their roles, performance expectations, and the policies to follow.This, in turn, promoted individual accountability and behaviors such as arriving to work on time and completing all expected tasks (Table 2, quotes i-j).
Balanced scorecards: Employees' performance was regularly monitored by using a tool called the balanced scorecard, which provided very specific metrics based on the job description of the employee (Table 2, quote k).Supervisors used balanced scorecards to develop individualized action plans to address deficiencies.Respondents noted that the metrics tracked on their own balanced scorecard related to broader QI goals, such as reducing mortality rates (Table 2, quote i).
Disciplinary action: Many respondents stressed that disciplinary action was taken when needed, and employees were let go if their performance was consistently poor.Clinicians were assessed on their skills and knowledge before being offered a contract renewal.Respondents said this was in contrast with the public facilities where it was difficult to terminate employees (Table 2, quotes m-n).
Accountability systems to foster professionalism: QMMH-IN used a variety of systems that promoted accountability, such as biometric clocking (Table 2, quote o).Another example was the use of employee numbers to record who had logged into a system that tracks movement of money from a cashier to the safe (Table 2, quote p).Respondents generally described these systems as powerful tools that increased discipline and professionalism.They perceived this as translating to increased punctuality, decreased theft, and overall improved performance (Table 2, quote q).A few respondents reported some employees were dissatisfied with the intense oversight and accountability systems (Table 2, quotes r, l).

Infrastructure, core systems, workflows, and internal referral network
The high quality and functionality of physical infrastructure, core hospital systems and workflows, and internal network collaboration were also perceived to facilitate QMMN-IN performance.
Facilities, equipment, and their maintenance: Nearly all respondents spoke highly of the QMMH-IN physical infrastructure, describing it as well-maintained, clean, and well-designed to ensure patient privacy (Table 2, quotes s-t).This was perceived to improve the well-being of not only patients, but also employees, who work better in a comfortable and safe environment.
Respondents generally felt necessary equipment was available and well-maintained.With a few exceptions, mostly related to delays in receiving parts from South Africa, respondents were pleased with the company contracted to provide, maintain, and repair the medical equipment, and felt it improved clinical performance and patient satisfaction (Table 2, quote u-v).
Core systems and workflows: When comparing to public facilities, respondents generally felt the core systems such as pharmacy and laboratory services facilitated performance, particularly emphasizing the availability of medications.Respondents felt that procuring supplies weekly and outsourcing when needed decreased pharmacy stock-outs (Table 2, quote w).Respondents felt this improved patient outcomes and shortened hospital stays.
Respondents had mixed opinions of the laboratory system, citing a recent change from subcontracted lab services to the lab being managed in-house.Despite challenges with the new, inhouse lab, most respondents still considered this core system a facilitator, highlighting the quick turnaround times and ability to track specimens digitally from collection through receipt of results ( Internal referrals and network collaboration: The system for referring patients from the filter clinics to the QMMH hospital also emerged as a perceived facilitator.Respondents felt that referral audits and regular communication through academic meetings between clinicians at the various network facilities improved the timeliness and quality of referrals.Collaboration across the network also allowed for other efficiencies that were perceived to improve patient care, such as the ability to share medications between sites (Table 2, quotes y-z).

BARRIERS TO QMMH-IN PERFORMANCE
Two major themes emerged as barriers to QMMH-IN performance: (1) challenges within human resource management; and (2) broader health system and referral network limitations (Table 3).

Human resource management
Recruitment and retention of adequate levels of staff and specialty clinicians were described as barriers to performance.
Recruitment and retention: Respondents felt that QMMH-IN performance was limited by its inability to recruit and retain experienced employees, primarily due to inadequate compensation.
Respondents from across departments expressed dissatisfaction with their salaries, in relation to the work they are doing, and in comparison to salaries thought to be offered at governmental health facilities (Table 3, quote a), non-governmental organizations, and private mining companies.One respondent specifically described that while most did not mind working longer hours than their government counterparts, they wanted appropriate compensation (Table 3, quote b).
Respondents felt inadequate compensation led to poor morale and high employee turnover in all departments, explaining QMMH-IN struggled to recruit experienced nurses and physicians, and then to keep them after they were trained (Table 2, quote c).They perceived this to affect patient outcomes since newer clinicians often do not have the necessary experience to provide the level of care expected at a referral hospital.
Staffing and specialists: Some respondents noted that staffing ratios and number of specialists had improved within QMMH-IN compared to before the PPP and to other hospitals.However, others expressed that these figures were still insufficient and limited network performance, noting specifically a lack of ICU and Emergency Medicine specialists (Table 3, quotes d-e).
Training: While some described the training offered by QMMH-IN positively, most respondents described a lack of training opportunities that limited employee potential.Some respondents felt the lack of emphasis on training and professional development for clinicians made QMMH-IN fall short of its contractual mandate (Table 3, quote f).Another respondent discussed the limited focus on capacity building in the broader health system (Table 3, quote g).

Lesotho health system and referral network
Limitations in structure and function of the district health system and referral network posed important barriers to QMMH's performance and ability to serve as the national referral hospital.

District health system capacity:
A common perspective among respondents was that Lesotho's district health system lacked capacity in terms of needed equipment, medications, and staff to appropriately mange patients.This resulted in a "flooding" of patients who should have been managed at the district level coming to QMMH instead (Table 3, quote i).Respondents described patients as preferring to seek care at QMMH-IN due to a lack of capacity at the district level (Table 3, quote j).
Inappropriate referrals: Respondents also described receiving referrals who are not medically complex and should not be at QMMH (Table 3, quotes i, k).Respondents suggest this pattern has contributed to a decline in skills and further reduction of capacity at the districts (Table 3, quote l).Other respondents perceived that some patients are referred too late and arrive with advanced disease, resulting in poor clinical outcomes (Table 3, quote m).The use of resources to manage  inappropriately referred cases at QMMH was perceived to have diverted resources away from cases that required specialty care, and overall leading to QMMH not performing at the level of a national referral hospital (Table 3, quote n).

PERSPECTIVES AND RECOMMENDATIONS ON TRANSITION OF QMMH-IN POST-PPP
At the time of the interviews, the early end of the PPP contract had not yet been announced and a transition in QMMH-IN management was anticipated to happen in approximately six years.
Respondents were asked what they anticipated to happen at the time of this transition and to provide recommendations for improvement now and at the time of transition.Table 4 outline the themes and illustrative quotes from their responses.
Respondents expressed concern over the anticipated transition of QMMH-IN to government management and many predicted a decline in hospital performance (Table 4, quote a).Some felt frustrated that, at the time of the interviews, they did not feel the government was actively planning for the transition, nor learning from what worked well at QMMH-IN in order to prepare for it (Table 4, quote b).One respondent detailed an earlier unsuccessful attempt to pilot the implementation of COHSASA quality standards at government hospitals to illustrate their concern over the management transition of QMMH-IN (Table 4, quote c).

Recommendations for transition
Respondent-generated suggestions specific to the transition of QMMH-IN to the governmental management are summarized below.
The first recommendation was to keep, reinforce, and expand upon what works well now, including culture of quality improvement, a focus on evidence-based practice, and well-functioning medication supply, equipment maintenance, and communication systems within the network.
To help achieve this, respondents suggested continuing to work with specific private contractors, especially in the early years of transition, to retain institutional knowledge and continue benefiting from well-established workflows (Table 4, quotes d-f).Respondents recommended the government invest in training managerial staff who will assume operations of the QMMN-IN to ensure they are adequately prepared for the transition (Table 4, quote g).Additionally, it was recommended to improve staffing levels and number of specialists by focusing on job satisfaction, recruitment, and retention.Specifically, respondents emphasized the need to offer employees training and career advancement opportunities and ensure salaries are competitive (Table 4, quotes h-k).
Furthermore, respondents suggested the government consider designating QMMH as a training facility, similar to how QEII previously functioned, to help maintain a standard of care for health providers working across the health system (Table 4, quote l).This could be part of an overall effort to invest in much needed strengthening the greater Lesotho health system.Lastly, respondents recommended improving the referral system between outside facilities and QMMH so that QMMH can function as a referral hospital as intended.The QMMH-IN internal referral network could then serve as a model for needed changes to the external referral network (Table 4, quotes m-n; Table 3 quote i).

DISCUSSION
QMMH-IN, as sub-Saharan Africa's first and largest integrated PPP, is an important global experiment of how to fund and deliver high-quality medical care in lower-resource settings.Through this research, we explored insights and lessons learned from the insider perspective of QMMH-IN employees just prior to the early termination of the PPP contract.Facilitators of QMMH-IN performance included a focus on quality improvement; accountability and discipline; and well-functioning infrastructure, core systems, and workflows.Many of these elements were also observed in the 2012-2013 evaluation of the network.Major barriers were related to human resource management and QMMH's relationship to the greater health system, both of which had  newly emerged since the 2012-2013 evaluation [12].At the time of data collection, although PPP partners were actively attempting to renegotiate the QMMN-IN contract, there was no known plan for an early termination of the PPP and transition in management.When asked about the anticipated contract end in six years, respondents expressed concern about the government's capacity to manage QMMH-IN and maintain the level of hospital performance observed under the PPP and provided key recommendations for consideration around the time of transition.Perspectives on the early PPP contact termination are explored elsewhere [25].As of mid-2021, the Government of Lesotho had assumed management responsibility of QMMH-IN.These findings may be relevant when making strategic planning decisions going forward.
We identified a strongly embedded culture of QI and accountability at QMMH-IN as a primary facilitator of the network's performance.Sustaining this culture will therefore be important for the continued success of QMMH-IN.Doing so requires an intentional and systematic strategy [26] that includes each of the foundational elements of QI culture, namely: leadership commitment, empowered employees, customer focus, a collaborative environment, and the maintenance of an explicit QI infrastructure, including continuous data collection and monitoring by dedicated employees [27].Employee empowerment, which was identified as a facilitator in the earlier evaluation of the network [12,17], appears to have declined in our 2020 evaluation in the setting of poor morale, and will need to be a focus of future efforts if this overall culture of QI and accountability is to be sustained.The continued use of the balanced scorecard or similar tool may be helpful to retain, as respondents in this study perceived it as motivating for employees.
Other research supports the usefulness of balanced scorecards in linking individual roles and organizational performance goals [28] and stimulating QI culture [29].Additionally, taking holistic view that includes sustaining workflows that ensure reliable procurement, quality assurance of needed medical products and technologies, and maintenance of the physical infrastructure and equipment cannot be overemphasized [30].Each of these pieces of the system is interdependent and overall builds to a what has been previously described at QMMN-IN as a "reliable work environment [12]." The primary barriers internal to QMMH-IN perceived to limit performance were related to human resource management, with low salaries in comparison to outside facilities and lack of investment in training opportunities driving poor recruitment and retention of experienced employees.Unanticipated wage increases of approximately 80% for government hospital workers announced in 2013 meant that QMMH-IN employees went from being paid 3-54% more than their governmental counterparts (depending on job category) to being paid less [9], partly due to a failure to renegotiate the PPP contract to take into account increased wage expenses.Financial strains on the network and the poor payment history by the Government of Lesotho [31] may have contributed to a decreased emphasis on training opportunities over time.It is widely recognized that the management, training, and retention of highly skilled medical staff is a key factor in health system performance and demands significant effort to sustain [32].
The main identified performance barrier external to QMMN-IN was the perception that lack of resources elsewhere in the health system was resulting in inappropriate referrals of lowcomplexity patients.This was also new in our analysis relative to the 2012-2013 QMMH evaluation [12], and is illustrative of how a PPP may influence supply and demand for healthcare over time.This barrier must be considered within the context of having no Maseru district hospital at the time, which undoubtedly exacerbated the number of patients presenting to QMMH-IN facilities [1].Additionally, similar to what was seen in the comparative evaluation of PPP-run versus publicly run district hospitals in India [33], respondents in our study reported that patients themselves were also driving the "flooding" of QMMN-IN due to perceived higher quality care.PPP design and implementation must consider not only the hospital network itself, but also the broader healthcare system, as neither operates in isolation and effective national healthcare delivery strategies must consider care across the continuum [3,8].

CONSIDERATIONS FOR IMPLEMENTERS AND MANAGEMENT OF PPPs
Below we summarize three considerations from these findings that may be of use to others interested in implementing healthcare PPPs, especially those in lower-resource contexts.
1) Build, embed and sustain a culture of QI and accountability that is supported by core systems, clinical and administrative workflows, and consistently maintained facility infrastructure.Our results suggest that this culture was a key driver of QMMH-IN performance and that maintaining it would be important for the continued performance of the hospital network.Some specific considerations include intensive succession planning for any new network managers, maintaining structures such as the Office of Quality and Risk, and continuing the use of accountability tools such as balanced scorecards.A follow-up study post-PPP could help to understand what happened with the transition and explore the degree to which this culture and the overall reliable work environment were sustained.This is responsive to identified gaps in the PPP literature including a lack of "whole life cycle" evaluations [34] and the need for evidence regarding transitions of healthcare PPPs [35].for adjustments to external conditions in order to continue to prioritize adequate human resource investment over time.The importance of contract flexibility and responsiveness to changing external factors has been echoed throughout the PPP literature [1,34,36].3) Invest in broader health system strengthening.Without adequate, concurrent investment in the health systems at the district and clinic level, QMMH-IN was unable to function as intended.An adequately resourced and capacitated health system must be the foundation for a PPP like QMMH for it to operate at the level of a national referral hospital.This would require more balanced investments at all levels of the health system from the beginning of the PPP agreement.Going forward post-PPP, QMMH-IN could support the greater health system by transitioning more fully into a medical training institution focused on building internal and external capacity.This is consistent with recommendations by the WHO [22] as well as those which were generated from the QMMH-IN baseline evaluation [8] and represents a missed opportunity within the QMMH-IN PPP.

LIMITATIONS
This study has several limitations.First the qualitative data explore, but do not attempt to measure the frequency of perspectives and attitudes.Second, interviews were conducted by Boston University researchers, which may have introduced a social desirability bias; however, as evidenced by the quotes, respondents seemed to feel free to express concerns and provide constructive comments on the PPP and QMMH-IN.Third, our sample of 26 included only five respondents from network clinics and thus our findings are likely more hospital-centric in nature.
In addition, the scope of this paper did not include perspectives from governmental officials in charge of the regulation and financing of QMMH, nor respondents from district hospitals.As such, the findings as a whole and specifically the recommendations regarding the Ministry of Health's role/management and greater district health system must be interpreted cautiously.

CONCLUSIONS
Healthcare PPPs are important and promising strategies to finance healthcare systems.It is critical to consider employees as key stakeholders who can help to elicit the nuances of the barriers and facilitators of PPP performance in varying contexts.Implementors of integrative PPPs in lowerresource settings should pay special attention to healthcare system allocation of resources, human resource investment over time, PPP contract flexibility, and succession planning as means of facilitating and sustaining hospital network performance.

REFLEXIVITY STATEMENT
Grounding our methods in reflexivity, here we provide details on authors' gender, seniority, field of expertise, role in the evaluation, and their relationship to the McGuire et al.

Table 2
Illustrative quotes from respondents on perceived facilitators of QMMH performance.Ellipses indicate removed text to shorten quotes, while preserving meaning.Square brackets contain text added by the authors to facilitate comprehension. Note:

. Routine internal and external monitoring as driver of performance c) "We monitor the
performance of the clinicians and the nurses.We do clinical audits to see whether they are conforming to the protocols and the clinical pathways (…) [We] come up with quality improvement projects that will improve from where we are and eliminate gaps that were identified."

dedicated office of quality and risk led staff actions to address gaps and improve quality g) "QMMH doesn
't joke, if there is a loss of life we have to sit down (...) to see what went wrong.The fish bone [diagram] is really scrutinized."What happens is on day-to-day, employees know what is expected of them because they have their job descriptions."-QMMH higher management, "Before I can assess the employee, we need to fill out the balance scorecard so that they can know which issues I am going to assess them on (…) non-clinical rolej) j) "We know what time we have to be in at work and what time to knockoff.Things with the PPP have been going so well, compared to where I was working before, because I would leave [early] at 1: 00pm and nobody will ask me anything.Here I know that even if nobody asks me anything, there are things I should follow.I have to come at a specific time.I have to do [specific work].There are guidelines, policies."-QMMH higher management, clinical role [The balanced scorecards] have helped in a positive way.People don't want to make any mistakes (…) [and] if they have made mistakes (…) we can rectify."-QMMH higher management, non-clinical rolel) l) "Even me, I have a balance scorecard (…) my goals are this: to decrease morbidity in the department, to decrease neonatal deaths.Every quarter I have to translate to where we left and where we are in this quarter.Do we see a decrease?And then be accountable to say what measures am I going to implement in the department to ensure that we achieve what reflected in the score card.(…) It is really well structured.Hence why a doctor who is not used to that gets frustrated.They get to a point where they are monitored, monthly, weekly, quarterly to say: 'but you are not performing.'So it really helps to keep the performance standards."-QMMH higher management, clinical role (Contd.)THEME SUB-THEME ILLUSTRATIVE QUOTES "It's the infrastructure.It's new and improved.People have access to a well-maintained facility."-QMMH higher management, non-clinical rolet) "The difference between us and the government is that we don't do long term procurement.We buy more regularly (…) so we don't necessarily experience long-term stockouts [at QMMH].If it is an essential medication, it is categorized into E, VI, HV -Essential, Very Important, and High Volume.You make your assessment.If it's something you feel a week is too long, you can't survive, [but that medication isn't available from the government stock,] we immediately outsource it from elsewhere."-QMMH higher management, non-clinical rolex) "The [internal] system of a collaboration between the [filter] clinics and hospital is perfect.Because (…) there is all this collaboration, at a high level with the heads of departments [passing] down all the information to the [staff] of the department.And the referral system, it's really well medication that really improves their lives.So when they [patients] go back to their original places, they need the same medications, and sometimes those people there don't have that medicine, it is only at the referral hospital.So, we said okay, the recipient hospital will borrow this much for the patient until they get theirs."-QMMH higher management, clinical role McGuire et al.Annals of Global Health DOI: 10.5334/aogh.4377 You won't arrive at work at 10:00 when you are supposed to arrive at 7:00.That means services are going to run on time.People don't steal the medications from the pharmacy (…) Even as staff [when I am sick], I know I have to consult with a doctor, pay the 15 Rand, get my medication.[This] is not the case in those other facilities.(…)This is why I said I can advocate for another PPP facility."-QMMHstaff, clinical roler) r) "They [management] has their eyes on the staff.They know what is happening where.Who is performing and who is not performing.We are [more] closely monitored than at many other places.I think that is the good thing that is happening.[However],I know there is also some dissatisfaction in certain ways [with this close monitoring]."-QMMHhigher management, clinical role III.Infrastructure, t) "In the wards there are cubicles, there are curtains where the patients are seen and you draw them.All our consultation rooms are private.(…)Patients are given the privacy they need."-QMMHhigher management, clinical roleu) u) "Having access to clinical services that didn't exist before, that's a big deal for me.Because for instance, the MRI machine didn't exist before, it [allows for] better diagnosis."-QMMHhigher management, non-clinical rolev) v) "If I report that my ultrasound machine is out of function, it's going to be repaired immediately.[Conversely]sometimes at Queen Elizabeth II, six months down the line you find the X-ray machine is still broken (…) So patient satisfaction goes with that, [at QMMH] you will not have to come several times and still find [equipment that is] not functional and be returned."-QMMHhigher management, clinical role x) "[QMMH is] incredible compared to Queen Elizabeth II, where you would have to run around and go look if you have got [laboratory] results [back].Here its digital (…) An ABG (arterial blood gas) you are going to get results in five minutes time.So when it comes to the lab, it's really effective.We even have a way of tracking the specimens."-QMMH staff, clinical role strategized (…) Among the audits I do in a regular basis, I [evaluate] to find out how many patients were referred.What was the outcome?What was the condition of the patient?Was it a delay in referring [the] patient?So all this we monitor on a regular basis.There has been a tremendous improvement."-Clinic higher management, clinical rolez) z) "The network really helps because I don't see one [facility] working alone in isolation.An example [is] exchanging of drugs, as in borrowing, maybe those that are due to expire.(...) They [patients] will be put on a particular

Table 2 ,
quote x).Other examples of specific workflows perceived to improve QMMN-IN performance included individualized delivery of medications to patients on the wards, stock monitoring, and computerized maintenance schedules for equipment.McGuire et al.
"A big factor driving change in performance is salary.The biggest tool you have in a hospital is the staff.It's very difficult to keep the staff if other ministerial departments pay more.We feel we are understaffed (...) the nurse-patient ratio is one nurse to ten patients.But given the work that we are doing here and the quality of work that we provide to our patients (…)[and]the type of patients that we treat here -those that could not be treated anywhere else (...) we feel we are severely understaffed.The hospital, from what we understood at the beginning, was to reduce referrals and to train people.Train doctors, specifically local doctors, so that they then care for most of the patients locally.That is not happening as expected (…) There has to be a lot more effort with regards to developing the doctors (…) "QMMH is a symptom of what is broken in the system.Patients are flooding QMMH because it's the only place that they feel they can get help.So QMMH ended up doubling [it's expected] numbers of patients (…) some of these patients, maybe caesarian section for fetal distress, could have been done at a district hospital but they say they don't have oxygen, so patients are referred (…) The entire health system needs to be strengthened."-Clinic staff, clinical role j) "There are no resources in government institutions.(...)You tell [patients] to go to a hospital [and] they cry, they don't want to go (…) the entire service delivery in government institutions is not functioning as one would expect it to (…) You walk into a [public] clinic and maybe there is only one nurse working there.It's very difficult.People queue for very long time.I think it's easier for people to trust Queen 'Mamahato rather than the government institutions."-QMMH staff, clinical role "Patients will be referred here [at QMMH] who don't need to be here (…) there was no linen at the district hospitals so they could not do a caesarian-section (...) We can have a better functioning system.[That is] our challenge.We get unnecessary referrals."-QMMH higher management, clinical role l) "[The existence of QMMH] has decreased the quality of care provided by the district hospitals because now if you go to the district hospital, people will just refer something that they could have treated locally.Refer.But we don't see that from the filter clinics (…) I think [the presence of QMMH] has taken away the clinical skills of people [working in the districts]."-QMMH higher management, clinical role m) "Patients are coming late, they are referred late, and therefore the outcome is bad.So we can't blame the hospital [QMMH] for the poor outcome of the patients.(…) Providers will waste time in the in private clinics up until it's late, they will send a patient to QMMH when it's late."-Clinic higher management, clinical role n) "The closing of Queen Elizabeth II caused a lot of havoc in the whole [health] system, because Maseru did not have a district hospital.Only recently Queen Elizabeth II was opened [again] and only the outpatient department.Now you find that QMMH has literally becomes the district hospital [and] the referral hospital.(…) Service provision has been affected by trying to share resources between managing primary cases and high-risk cases.And the bulk of patients that come here are primary care patients."-QMMH higher management, clinical role " -QMMH higher management, non-clinical role b) "As for these shifts we are working, most people like them.They are used to working 12 hours shifts, while in government people are working 8 [or] 9-hour shifts.They say they are fine with the shifts.They only complain about money."-QMMH staff, clinical role c) "For a tertiary hospital we should have people who are more experienced, but that's the opposite because of issues of salaries we usually get.So [that is] quite challenging.We have newly graduated nurses coming to work here (...) we need people with skills that are mature."-QMMH staff, clinical role e) "There are no ICU specialists; [nor] emergency specialist."-QMMH higher management, clinical role We don't have a well-organized training program which should be there."-QMMH higher management, clinical role g) "Queen Mamohato [is] not really empowering the [rest of the health] system (…) [The] job description talks about external capacitation, [via] internal and external interaction.But most of the time, the current system is not flexible enough to allow external participation."-QMMH higher management, clinical

Table 3
Illustrative quotes from respondents on perceived on barriers QMMH-IN performance.ICU = Intensive Care Unit; QMMH = Queen 'Mamohato Memorial Hospital.Note: Ellipses indicate removed text to shorten quotes, while preserving meaning.Square brackets contain text added by the authors to facilitate comprehension.McGuire et al.
"Just see how the government hospitals are managed.How the services are in the government hospital.So if the hospital is given back to the same management, all of this [at QMMH] will fall.That is my personal opinion."-QMMH higher management, clinical role "Keep on doing the good things that you are doing.Learn about the new things that are coming up, and make sure that you improve and adhere to the new research and evidence-based practice."-QMMH higher management, clinical role e) "In regard [to the] availability of medications.We already[have] the strategies of how we make sure things are available (...) which should be maintained (…

2 )
Invest in people as substantively as in infrastructure, equipment, and core systems.Employee morale is crucial to hospital network performance; we observed a perceived lack of investment in employees over time, including lower pay than government counterparts and insufficient training opportunities.QMMN-IN did not respond to external changes to governmental healthcare worker wages, potentially to the detriment of network performance.Integrative PPP agreements should be flexible enough to allow McGuire et al.Annals of Global Health DOI: 10.5334/aogh.4377 QMMH-IN PPP.ELNN is a Mosotho while all other study authors are American.BWJ is male while the rest of authors are female.ELNN is a nurse, registered nurse-midwife, holds a Master of Public Health degree and is currently a PhD candidate at Sefako Makgatho University of Health Sciences.CMM and BWJ are family physicians.CMM holds a Master of Science degree in health systems and services research.ELNN, CMM, and BWJ have clinical experience in district hospitals in Lesotho but not within QMMH-IN.All three are also affiliated with Lesotho-Boston Health Alliance, a Lesotho-based organization who served as the implementing partner for the overall evaluation.At the time of data collection, JLK was a Boston University research fellow, with five years of experience in conducting mixed-methods health systems research in sub-Saharan Africa.TN was a Doctor of Public Health candidate at Boston University.JLK and TN, the study interviewers, were not involved in the previous work in Lesotho conducted by Boston University, and held no prior beliefs regarding the performance of QMMH-IN.TV and NAS are both senior public health researchers with a combined 49 years of experience in mixed-methods evaluations.